Severe hypomagnesaemia due to lansoprazole.

A 71-year-old woman, who had been taking lansoprazole for 18 months for dyspepsia, presented with vomiting, thought to be due to gallstones, and was found to have severe hypomagnesaemia. She was treated with intravenous and then oral magnesium, and discharged, but was soon readmitted with symptoms due to hypomagnesaemia, and again treated with magnesium supplementation. No other recognised cause for hypomagnesaemia was found. Because of recent reports of hypomagnesaemia due to other proton pump inhibitors, lansoprazole was changed to ranitidine. Her symptoms resolved and the serum magnesium returned to normal. Oral magnesium supplementation was stopped with no return of symptoms or hypomagnesaemia. Such an association must be borne in mind with suggestive symptoms in patients on long term proton pump inhibitors; their cessation or change to H(2) receptor antagonists is likely to correct the situation rapidly.

Impact of practice size on delivery of diabetes care before and after the Quality and Outcomes Framework implementation.

General practice characteristics are important for healthcare providers to maximise outcomes. Although different aspects of general practice characteristics have been studied previously, the impact of practice size on the delivery of care has been sparsely studied, particularly in relation to diabetes care. This brief report presents a longitudinal study in Shropshire (66 practices, 16,858 patients with diabetes) to assess the impact of practice size on diabetes care before and after implementation of the Quality and Outcomes Framework (QOF). Achievement of glycaemic control targets was better before the QOF for larger as compared to smaller practices (P=0.02 and P=0.003 for haemoglobin A1c [HbA1c]

Diabetes care and the new GMS contract: the evidence for a whole county.

The aim of this study was to assess the impact of the Quality and Outcomes Framework (QOF) of the new GP contract on diabetes care in Shropshire, which has a total population of approximately 460 000. The mean percentage of patients achieving each of the quality indicators in each practice in Shropshire, before and after the implementation of the QOF was calculated. All 16 867 patients with diabetes from all 66 Shropshire practices were included. There were significant improvements in the percentage of patients achieving targets for all quality indicators between April 2004 to March 2006 (P<0.001).

Methicillin-resistant Staphylococcus aureus (MRSA) isolation from diabetic foot ulcers correlates with nasal MRSA carriage.

Methicillin-resistant Staphylococcus aureus is increasingly isolated from diabetic foot ulcers, and may be associated with an adverse prognosis. We have explored the relationship between MRSA isolation from foot ulcers and nasal MRSA carriage. Over a 12 month period, 65 consecutively attending patients with diabetic foot ulceration were recruited. Demographic information was collected, and the ulcer and nose swabbed bacteriologically using standard techniques. The patients were mean age 61 year, diabetes duration 14 year, and HbA1c 8.5%. There were 61% male and 85% with type 2 diabetes. Ulcers were neuropathic in 55%, ischaemic in 14% and neuroischaemic in 31%. MRSA was isolated from 12 (19%) ulcers, and 11 (17%) had nasal carriage. Of the MRSA positive ulcer patients 7/12 (58%) had nasal MRSA carriage, compared with 4/53 (8%) with MRSA negative ulcers (p<0.0003). We conclude that nasal MRSA carriage in diabetic patients is a significant risk factor for foot ulcer MRSA infection.

The development of non-insulin-dependent diabetes after total body irradiation and bone marrow transplantation in adolescence: a case report and literature review.

A 6-yr-old-child received total body irradiation (TBI) and bone marrow transplantation (BMT) for relapsed acute lymphocytic leukemia. Nine years later, he developed diabetes mellitus (DM). He was started on basal bolus insulin therapy. Islet cell and anti-GAD antibodies were negative. Insulin and C-peptide levels were elevated consistent with insulin resistance (IR), even though his body mass index (BMI) was only 19.5. Hepatocyte nuclear factor (HNF-1alpha) mutation was not detected. Insulin was stopped and hemoglobin Alc (HbA1c) stabilized at 6.5% on gliclazide 40 mg/day. TBI has rarely been associated with IR and the development of diabetes. These patients can be managed with oral hypoglycemic agents and do not necessarily require insulin. Patients who received BMT and TBI may require long-term monitoring of glucose and lipid metabolism.

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology.

OBJECTIVE: Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study aims to examine the long-term outcome in terms of amputations and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology. RESEARCH DESIGN AND METHODS: Patients presenting with new ulcers (duration <1 month) to a dedicated diabetic foot clinic between 1994 and 1998 were studied. Outcomes were determined until March 2000 (or death) from podiatry, hospital, and district registers. Baseline clinical examination was done to classify ulcers as neuropathic, ischemic, or neuroischemic. Five-year amputation and mortality rates were derived from Kaplan-Meier survival analysis curves. RESULTS: Of the 185 patients studied, 41% had peripheral vascular disease (PVD) and 61% had neuropathy; 45%, 16%, and 24% of patients had neuropathic, ischemic, and neuroischemic ulcers, respectively. The mean follow-up period was 34 months (range 1-65) including survivors and patients who died during the study period. Five-year amputation rates were higher for ischemic (29%) and neuroischemic (25%) than neuropathic (11%) ulcers. Five-year mortality was 45%, 18%, and 55% for neuropathic, neuroischemic, and ischemic ulcers, respectively. Mortality was higher in ischemic ulcers than neuropathic ulcers. On multivariate regression analysis, only increasing age predicted shorter survival time. CONCLUSIONS: All types of diabetic foot ulcers are associated with high morbidity and mortality. The increased mortality appears to be independent of factors increasing ulcer risk-that is, neuropathy and PVD-in patients with established foot ulcers.